Biomedical subjects
D C Bartolo
Publications and source records attributed to D C Bartolo.
Anterior sphincter plication and levatorplasty in the treatment of faecal incontinence.
The surgical treatment of faecal incontinence has been traditionally divided into sphincteroplasty for sphincter disruption and postanal repair for idiopathic cases. However, many studies have failed to show a correlation between outcome and change in the anorectal angle. This study was carried out to determine the effectiveness of anterior sphincteroplasty and levatorplasty in the treatment of faecal incontinence, regardless of aetiology. Thirty consecutive patients underwent surgery, 14 with traumatic sphincter injuries and 16 with idiopathic faecal incontinence. A satisfactory clinical result was obtained in ten (71 per cent) patients in the traumatic group and in ten (62 per cent) in the idiopathic group. This was associated with a significant increase in maximum voluntary contraction pressure in the traumatic group and in those patients who had a good result in the idiopathic group (traumatic: preoperative median 80 cmH2O (range 50-115 cmH2O) versus postoperative 115 cmH2O (75-290 cmH2O), P less than 0.005; idiopathic: preoperative 105 cmH2O (45-190 cmH2O) versus postoperative 120 cmH2O (45-230 cmH2O), P less than 0.05; Wilcoxon paired signed ranks test). There was also significant improvement in anal sensation in the upper anal canal in both groups (traumatic: preoperative mean 17 mA versus postoperative 11 mA, P less than 0.05; idiopathic: preoperative 24 mA versus postoperative 9 mA, P less than 0.02). The anorectal angle increased in the idiopathic group at rest (preoperative median 105 degrees (range 86-152 degrees) versus postoperative 118 degrees (95-180 degrees), P less than 0.05). In conclusion, the type of approach (anterior or posterior) and the anorectal angle are irrelevant to the outcome of surgery for idiopathic faecal incontinence. Success appears to be related more to improved sphincter pressure and anal sensation.
Differences in anal sensation in continent and incontinent patients with perineal descent.
Neuropathic damage secondary to pelvic floor descent is considered to be an important aetiological factor in idiopathic faecal incontinence. Perineal descent however does not necessarily result in a loss of motor function or incontinence. To elucidate the role of anal sensation in the continence mechanism we measured mucosal electrosensitivity and thermal sensitivity in normal controls and in both continent and incontinent patients with perineal descent. A catheter carrying two platinum electrodes was used to assess mucosal electrosensitivity and a water perfused thermode 1 cm long to measure thermal sensory thresholds. In addition, routine anal manometry was performed. The degree of perineal descent and anorectal angle was assessed radiographically. Anal sensation was largely preserved in continent patients with perineal descent (Controls vs continent perineal descent, Mucosal electrosensitivity (ma), lower anal canal: 4 (2-7) vs 5 (2.6-8) ns; middle anal canal 4 (2-7) vs 4.2 (2-15) ns; upper anal canal 6.5 (4-13) vs 8.3 (3.6-16) p less than 0.05, thermal sensitivity, median threshold (degrees C), lower anal canal 0.92 (0.5-2.5) vs 0.95 (0.3-3.6) ns; middle anal canal 0.83 (0.4-1.5) vs 0.75 (0.2-2) ns; upper anal canal 0.98 (0.6-2.4) vs 2.2 (0.5-4.8) p less than 0.05). There was a severe impairment of anal sensation in the incontinent patients with perineal descent despite a greater degree of perineal descent in the continent group. Loss of anal sensation is associated with the development of incontinence and is likely to be involved in the pathogenesis of the condition.
A comparison between Marlex and resection rectopexy.
UNLABELLED: The role of sphincter recovery, and postoperative constipation in the recovery of continence after both anterior and posterior Marlex rectopexy (APR) and resection and rectopexy (RR) has been investigated. Neither bowel frequency or straining at stool, nor incomplete emptying is significantly altered in either group although emptying is improved overall. Upper anal canal electrosensitivity is reduced postoperatively (APR 18 mA preoperatively vs. 13 postoperatively [n.s.], RR 15 vs. 13) as is the volume for appreciation of rectal filling (APR 77.5 ml preoperatively vs. 50 postoperatively, RR 55 ml vs 32.5). CONCLUSION: Continence postoperatively does not directly depend on sphincter recovery or postoperative constipation. Improved anorectal sensation may be an important factor in postoperative improvement.
Assessment of microtransducers in anorectal manometry.
It has been reported that microtransducer-tipped catheters (transducer) produce reliable reproducible measurements which correlate well with water-filled balloon systems. Maximum resting pressure (MRP) and maximum voluntary contraction pressures (MVC) were compared using a standard station pull-through technique in 12 patients. There was a poor correlation for both MRP: microballoon, 115 cmH2O (60-160 cmH2O); transducer 60 (20-110), r = 0.62, P less than 0.05, and MVC: microballoon, 202 (60-375); transducer, 175 (60-210), r = 0.42, n.s. To determine whether this was due to radial variation in pressures measured by the transducer, we studied a further 39 patients with both systems. At each station, transducer measurements were made at each of four quadrants. We found better correlation for MRP: microballoon, 100 (40-175); transducer, 66 (34-120), r = 0.72, P less than 0.001, and MVC: microballoon, 225 (55-650); transducer, 180 (50-470), r = 0.87, P less than 0.001, but a significant radial variation for the transducer where rotation reduced MRP pressure measurements by 21 per cent (0-600 per cent), and MVC 17 per cent (0-76 per cent). Moreover there was a significant difference between anterior and posterior MRP in the upper anal canal, anterior 35 (5-80) versus posterior 25 (10-60), P less than 0.05. These results account for the poor correlation between random positioning of the microtransducer-tipped catheter and indicate that radial orientation must be taken into account.
Anorectal sampling: a comparison of normal and incontinent patients.
It has been suggested that sampling of rectal contents by the anal canal may play a role in the continence mechanism. To investigate this concept we studied 18 patients with faecal incontinence and 18 age and sex matched controls. A microtransducer catheter was positioned so that pressures were recorded from the rectum, the junction of the upper and middle thirds of the anal canal and the lower anal canal. Recordings were taken at rest and while distending the rectum with air in a balloon, and then with air injected freely into the rectum. Sampling (equalization of the rectal and upper anal canal pressures) was seen to occur spontaneously in 16 of the controls and only 6 of the incontinent group (P less than 0.02) and induced sampling occurred at a higher rectal volume in the incontinent group than in controls for freely injected air (P less than 0.002). Defective anorectal sampling may be an important contributory factor in the pathogenesis of anorectal incontinence.
Prospective study of conservative and operative treatment for faecal incontinence.
To assess the functional results of treatment of faecal incontinence we carried out physiological and radiological measurements in 46 patients and 20 controls. Twenty patients were selected for conservative treatment and 26 for surgery (including 17 postanal repairs and 6 anterior sphincter repairs). The degree of incontinence was scored before and after treatment and postoperative investigations carried out on 17 patients (11 postanal repairs). Forty per cent of the conservative treatment group had a successful result compared with sixty-five per cent of the operative group as a whole and fifty-nine per cent of the postanal repair patients. Resting and 'squeeze' anal canal pressures were improved following postanal repair as was upper anal canal sensation but there was no change in the anorectal angle. We conclude that the anorectal angle is not crucial in maintaining continence.
Sensory discrimination and dynamic activity in the anorectum: evidence using a new ambulatory technique.
The anal canal in health is extremely sensitive to thermal stimuli, If temperature sensation plays a part in sensory discrimination two conditions must be fulfilled: there must be a temperature gradient along the anorectum and rectal contents must be able to come into contact with the sensitive anal mucosa. In a study of 53 normal subjects we demonstrated this temperature gradient with a median temperature difference between the rectum and lower, mid and upper anal canal of 0.4, 0.2 and 0.1 degrees C respectively. The second condition was examined in 15 normal ambulatory subjects by measuring mid-anal sphincter (SP) and rectal pressures (RP) with a microtransducer catheter. The signals were digitalized and recorded in a portable electronic memory for later computer display, and analysis. Marked spontaneous sphincter relaxation resulting in equalization of RP and SP occurred 7 times per hour (1-4). The conscious sensation of the presence of flatus was associated with an SP reduction of 30 mmHg (20-50 mmHg) and an RP increase of 7 mmHg (0-15 mmHg), such that RP greater than or equal to SP in 80 per cent of 144 recorded events. Using this new technique we have demonstrated the highly dynamic nature of the anal sphincter. Several times an hour the sphincter relaxes with subsequent equalization of rectal and anal pressures, allowing entry of rectal contents into the anal canal so that its presence and nature can be determined.
Slow transit constipation. Comparison between patients with or without previous hysterectomy.
We have studied 31 patients with slow transit constipation. Fourteen developed severe symptoms following a hysterectomy, while the remainder had symptoms arising de novo and unrelated to pelvic surgery. To establish whether there were specific abnormalities which might be linked to hysterectomy, we compared the two groups. Rectosigmoid motility was impaired in the de novo group. Functional sphincter length, maximum resting anal canal pressure, and the rectoanal inhibitory reflex were not significantly different from controls. The majority of patients were able to significantly increase the anorectal angle on straining to defecate. Patients in the de novo group had a higher sensory threshold for rectal filling compared with controls, whereas the posthysterectomy group was not significantly different. Electromyography of the external sphincter showed failure of appropriate inhibition of resting activity in 57% of the de novo and 38% of posthysterectomy patients. The de novo group had hypoactivity of the rectosigmoid and an insensitive rectum. The abnormality in the hysterectomy group is less clear and any precise link between slow transit constipation and hysterectomy remains obscure.
An analysis of rectal morphology in obstructed defaecation.
Obstructed defaecation in the descending perineum syndrome has been attributed to anterior mucosal prolapse. Manometric and radiological measurements together with evacuation proctograms in 49 patients with obstructed defaecation and normal whole gut transit times were carried out and compared in a total of 25 controls. Proctography delineated four groups: (I) puborectalis accentuation, n = 11; (II) rectal intussusception, n = 25; (III) anterior rectal wall prolapse, n = 11; (IV) rectocele, n = 2. The anorectal angle at rest, maximum basal sphincter pressures and the rectoanal inhibitory reflex did not differ between the groups and controls. Group III achieved a greater increase in anorectal angle on straining than controls. Groups II and III exhibited significant perineal descent below the pubococcygeal line whereas group I did not. In perineal descent intussusception was the commonest morphological abnormality associated with obstructed defaecation. Isolated anterior mucosal prolapse was not observed, making local treatment aimed at reducing its bulk questionable.
Anal sensation and the continence mechanism.
Thermal sensation is thought to be important in sensory discrimination between different substances. The aim of this study was to determine the thermal sensitivity in the anal canal in continent patients with hemorrhoids (N = 20), a group that has been reported to have a sensory deficit, and to compare the results with control subjects (N = 40) and patients with idiopathic fecal incontinence (IFI) (N = 22). Anal manometry was performed and sensation to mucosal electrostimulation and temperature change in the lower, middle, and upper zones of the anal canal assessed. Thermal sensation was impaired in the hemorrhoid group as compared with controls, but not to the same degree as in IFI (e.g., median thermal sensitivity in mid anal canal, control 0.9 degrees C, hemorrhoid 1.2 degrees C, IFI 2.0 degrees C, P less than .05 and less than .001, respectively). The correlation between the two tests of sensation was 0.54 (P less than .001) and the reproducibility of thermal sensory thresholds was 0.82 (P less than .001). In conclusion, patients with hemorrhoids have a mild anal sensory deficit, but continence in this group is likely to be augmented by other factors.
Preservation of faecal continence during rises in ultra-abdominal pressure.
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Intra-operative air testing: an audit on rectal anastomosis.
Thirty three patients having an anastomosis to the rectum were studied prospectively to determine the usefulness of intra-operative air testing. The pelvis was filled with saline and the anastomosis was distended with air. Any leaks demonstrated were oversewn. A Gastrografin enema was performed on all the patients on the eighth postoperative day. Overall, there were 4 (12%) clinical leaks and 10 (30%) radiological leaks. In six patients with air leaks demonstrated at operation, two had a radiological leak, one of which presented clinically as well. We believe that in the other four patients a potential leak was probably avoided as a result of intra-operative air testing. This technique is simple, safe and effective and probably helps reduce leakage after colorectal anastomosis.
Anorectal temperature sensation: a comparison of normal and incontinent patients.
In the skin, temperature sensation plays an important role in discriminating between gas, liquid and solid. To elucidate the role of temperature sensation in idiopathic faecal incontinence we studied the minimum detectable temperature change in the lower, middle and upper zones of the anal canal and rectum in 33 normal subjects, and 20 patients with idiopathic faecal incontinence. A water perfused thermode was used to vary anorectal temperature from 37 degrees C down to 32.5 degrees C and up to 41.5 degrees C. The temperature change was reported by the patient as the thermode temperature varied from 37 degrees C to each extreme and on return to base line. The anal canal in the control group was highly sensitive to temperature change, the lower rectum was significantly less sensitive (P less than 0.0001). At each level in the anal canal and lower rectum the incontinent group were significantly less sensitive than their controls (P less than 0.005). The mid-rectum had no appreciable sensation in either group. We consider that this sensory deficit may be an important factor in idiopathic faecal incontinence.
Submucosal versus ligation excision haemorrhoidectomy: a comparison of anal sensation, anal sphincter manometry and postoperative pain and function.
Submucosal (SM) and ligation excision (LE) haemorrhoidectomy were compared to establish whether SM is a less painful procedure and whether anal sensation is better preserved by SM, and, if so, how this relates to postoperative function. There were 18 SM and 22 LE patients. Anal sphincter manometry and anal mucosal electrosensitivity were measured pre-operatively and 6 weeks after surgery. Postoperative pain was assessed by linear analogue scale. Anal sphincter pressures which were high pre-operatively fell to normal after surgery. Neither operation affected functional sphincter length or the recto-anal inhibitory reflex. Forty per cent of patients showed ultraslow waves on sphincter motility studies. These were associated with the highest pressures and in all but three cases disappeared after surgery. There were no differences in postoperative pain scores between the two techniques but there was a wide range from no pain to very severe pain in both groups. Submucosal haemorrhoidectomy preserved anal sensation better than ligation excision but this was not reflected in improved function. There was minor leakage and soiling in 50 per cent of patients from both groups and two SM and LE patients had initial faecal incontinence. All these symptoms had resolved by 6 weeks.
Psoas abscess in Bristol: a 10-year review.
A consecutive series of 16 cases of psoas abscess managed over a 10-year period at the Bristol Royal Infirmary is presented. Tuberculosis accounted for 4 patients all normally resident in the United Kingdom. Intraabdominal inflammatory disorders accounted for 9 of the cases with Crohn's disease being the commonest of these with 5 cases. The remaining patients comprised 3 with primary staphylococcal abscesses, one appendicitis, one diverticulitis and 2 with colonic carcinoma. Diagnostic delay was common. Ultrasonography together with guided aspiration of pus was the most useful investigation giving the diagnosis in cases due to tuberculosis and staphylococci. The presence of gut associated organisms was indicative of gastrointestinal pathology. Four patients died and significant morbidity occurred in a further 5. We recommend effective dependent drainage together with resection of diseased gut in the cases of gastrointestinal origin.
Polydioxanone suture in the gastrointestinal tract.
A randomized prospective trial was undertaken of polydioxanone suture (PDS) versus conventional suture material in 98 patients undergoing anastomoses in the gastrointestinal tract. Nine patients died within 6 months of surgery, one of these being related to an anastomotic leak. All other patients were followed up for between one and three and a half years. In 57 colonic anastomoses, 30 were randomized to a single layer of 2/0 (BPC) interrupted PDS and 27 to a single of 2/0 (BPC) interrupted silk. Follow up sigmoidoscopy and barium enemas were used to confirm the clinical suspicion of 6 benign anastomotic strictures, 5 of which occurred in the PDS group. At this stage, the colonic arm of the trial was discontinued because the 19% stricture rate with PDS was deemed unacceptable. In a second limb of the study, patients were randomized to two layers of 2/0 (BPC) continuous PDS or 2/0 (BPC) continuous chromic catgut. There were no significant differences in 32 gastric or small bowel anastomoses and in particular, no anastomotic strictures were apparent. The reasons for the high rate of stricture formation when using PDS for large bowel anastomoses are unclear. However, it would seem to be a suitable alternative to chromic catgut when confined to the stomach and small intestine.